Symptoms and Medicines

Symptoms and Medicines

Symptoms commonly observed in the last days of life infographic - Terminal restlessness, anxiety, dyspnoea, nausea and vomiting, pain, respiratory secretionsThese pages are a resource to guide evidence-based practice in the care of older people in the last days of their life (terminal phase).

If you require other prescribing advice for more long-term palliative care, refer to the Therapeutic Guidelines (subscription required). You can also download the free CareSearchgp App which covers this content.

Recognising the active dying phase

Recognising or diagnosing dying is a vital first step in ensuring appropriate terminal care is in place.

A person who is actively dying might be bedbound and unable to swallow. Other signs include:

  • poor responsiveness to verbal or physical stimuli
  • limited or no urine output
  • changes in breathing pattern
  • signs of peripheral shutdown.

Clinicians need to consider the needs of the person and the appropriateness of submitting someone showing these signs to ongoing investigations. When a person has been diagnosed as dying, the goals of care should change to managing the terminal phase.

Changing goals of care

This diagnosis is the opportunity to support shared decision-making and to design care through conversations with the person and their family and carers. Recognising dying helps avoid unnecessary, unwanted, or uncomfortable care options, including hospital transfers and resuscitation. If a person dies peacefully without needless suffering, the family and carers have the best opportunity to see the death as a good death and may have fewer difficulties as they grieve.

The identification that someone is in the terminal phase should trigger a review of care priorities within the clinical team. Priorities now pivot to:

  • talking to the person, the family and carers
  • managing symptoms
  • ensuring medicines are available for symptom management
  • withdrawing non-essential medicines
  • advising other health professionals involved in the person’s care.

All care of a person in the terminal phase should take into consideration any advance directive or advance care plan in place. Clear and sensitive communication with family members is also important at this stage so that they understand what is happening and what it means.

Anticipating the end of life

The terminal phase should be anticipated so that medicines can be obtained and available before symptoms arise and when the person needs them. This ‘anticipatory prescribing' ensures prompt symptom control and can avoid unnecessary stress, discomfort, and escalation of care.

Anticipating the terminal phase and planning for it requires proactive multidisciplinary collaborations. The multidisciplinary care team is likely to include the general practitioner, nurse practitioner, nursing staff, care staff, the carer, and the community pharmacist. The local palliative care team might also be involved.

Managing symptoms

In the terminal phase, physiological changes as the body shuts down and changes in the underlying illness contribute to some expected symptoms. These include anxiety, dyspnoea, nausea and vomiting, pain, respiratory secretions, and terminal restlessness. Subcutaneous medicines are typically used to manage symptoms in the terminal phase, due to the incidence of dysphagia.

Find out more about each symptom and link to resources to help you with their management here.

Page last updated 05 March 2024